Anthony V. Benedetto

Adverse Events Associated With Mohs Micrographic Surgery Multicenter Prospective Cohort Study of 20 821 Cases at 23 Centers

IMPORTANCE Detailed information regarding perioperative risk and adverse events associated with Mohs micrographic surgery (MMS) can guide clinical management. Much of the data regarding complications of MMS are anecdotal or report findings from single centers or single events. OBJECTIVES To quantify adverse events associated with MMS and detect differences relevant to safety. DESIGN, SETTING, AND PARTICIPANTS Multicenter prospective inception cohort study of 21 private and 2 institutional US ambulatory referral centers for MMS. Participants were a consecutive sample of patients presenting with MMS for 35 weeks at each center, with staggered start times. EXPOSURE Mohs micrographic surgery. MAIN OUTCOMES AND MEASURES Intraoperative and postoperative minor and serious adverse events. RESULTS Among 20 821 MMS procedures, 149 adverse events (0.72%), including 4 serious events (0.02%), and no deaths were reported. Common adverse events reported were infections (61.1%), dehiscence and partial or full necrosis (20.1%), and bleeding and hematoma (15.4%). Most bleeding and wound-healing complications occurred in patients receiving anticoagulation therapy. Use of some antiseptics and antibiotics and sterile gloves during MMS were associated with modest reduction of risk for adverse events. CONCLUSIONS AND RELEVANCE Mohs micrographic surgery is safe, with a very low rate of adverse events, an exceedingly low rate of serious adverse events, and an undetectable mortality rate. Common complications include infections, followed by impaired wound healing and bleeding. Bleeding and wound-healing issues are often associated with preexisting anticoagulation therapy, which is nonetheless managed safely during MMS. We are not certain whether the small effects seen with the use of sterile gloves and antiseptics and antibiotics are clinically significant and whether wide-scale practice changes would be cost-effective given the small risk reductions.

Intralesional electrodesiccation of syringomas.

BACKGROUND. Syringomas are common, benign adnexal tumors. In the periorbital area, they pose a cosmetic dilemma for both patients and physicians alike. Many different therapeutic modalities potentially can cause scarring, and recurrences are common. OBJECTIVE. To develop a treatment method that minimizes scarring and subsequent recurrences. method. Each syringoma is treated with short bursts of high frequency low voltage electrodesiccation delivered with a fine needle electrode that is inserted into the center of the syringoma, as deeply as the reticular dermis. RESULTS. Twelve patients treated over a 4‐year period showed no permanent adverse effects postoperatsivly and no recurrences. CONCLUSION. Intralesional electrodesiccation is a safe, nonscarring and, reliable method that can be used to eradicate periorbital syringomas.

Facial skin rejuvenation: Ablative laser resurfacing, chemical peels, or photodynamic therapy? Facts and controversies

Patients and cosmetic surgeons continue to develop innovative devices and techniques in search of the elusive fountain of youth. Our efforts in the past decade can be distilled to three primary approaches: refinement of existing technologies (ablative lasers); refinement of tried-and-true techniques (chemical peeling); and innovative use of new technologies (photorejuvenation). In this contribution, the authors discuss how these three approaches are used to achieve facial skin rejuvenation. Specifically, the authors compare and contrast the clinical benefits and disadvantages of the ablative fractionated and unfractionated carbon dioxide resurfacing lasers, medium-depth and deep chemical peeling, and the combination of photodynamic therapy with intense-pulsed light.

Automated 15‐Minute Cytokeratin 7 Immunostaining Protocol for Extramammary Paget's Disease in Mohs Micrographic Surgery

Extramammary Paget’s disease (EMPD) is a rare cutaneous neoplasm with a propensity for wide local spread and indistinguishable clinical borders. Local excision with wide margins yields a recurrence rate of 33% to 60%, whereas Mohs micrographic surgery (MMS) decreases recurrences to 16%. Although better than conventional surgery, the MMS recurrence rate for EMPD is strikingly higher than for other skin cancers treated using MMS. Possible explanations include the noncontiguous nature of EMPD and difficulty recognizing Paget’s cells in hematoxylin and eosin (H&E)-stained frozen sections, especially in the presence of freeze artifact.

Successful treatment of nonhealing scalp wounds using a silicone gel.

Of frequent debate among dermatologic surgeons is what should be done with regard to anticoagulant therapy before dermatologic surgery. Bleeding after surgery is potentially inconvenient to manage and may expose patients to additional procedures or affect final cosmetic outcome, but postoperative bleeding from a dermatologic procedure is easier to manage than a stroke or embolus that may happen during discontinuation of drugs. In 2012, the American College of Chest Physicians recommended continuing warfarin or aspirin perioperatively and optimizing local hemostasis during minor dermatologic procedures. There may be instances in which reduction or cessation of anticoagulation is warranted. In such instances, the decision is best made on an individual basis with the explicit involvement of the prescribing provider. Cessation of anticoagulation before dermatologic surgery does not appear warranted under usual circumstances.

Antimicrobials in dermatologic surgery: Facts and controversies

The two main uses of antimicrobials in dermatologic surgery include prophylaxis for bacteremia and prevention of localized surgical skin infection (LSSI). Bacteremia can result in hematogenous surgical infections such as infective endocarditis and prosthetic joint infection. Comprehensive guidelines from the American Heart Society (AHA), American Dental Association (ADA), and the American Academy of Orthopedic Surgeons (AAOS) have significantly reduced the number of patients in which prophylaxis is indicated for hematogenous surgical infection. The use of antimicrobials for localized surgical skin infection in dermatology is controversial. Although the overall trend in the literature supports the decreased use of antimicrobials in dermatologic surgery as a whole, it is important to know which situations still warrant antibiotics. This contribution will address the updated guidelines of the AHA, ADA, and AAOS, evidence-based techniques to decrease localized surgical skin infections, and situations in which antibiotics should be considered during dermatologic surgery.

Lasers in dermatology: unapproved treatments

It is now almost 40 years since lasers were first introduced to treat various diseases of the skin. Ordinarily, lasers are identified by the specific wavelength of light they emit, which influences a specific target, eliciting a particular effect. This effect can be destruction of a physical target or an alteration of a physiologic process, depending on the wavelength. In the United States, lasers come under the jurisdiction of the Food and Drug Administration (FDA). For the FDA to approve a laser, it must go through a series of rigorous clinical trials, similar to those performed for the approval of a drug. Before a laser can be marketed and distributed for a particular indication, carefully controlled efficacy and safety trials on animals and humans must be performed. Because a laser is considered a device, additional official indications can be added to a laser’s list of applications without repeatedly having to go through the stringent approval process and early phase clinical trials. This can be accomplished through a 510K provision of the FDA regulations. This provision states that if a new indication is an extension of an already approved application of a medical device, the new indication can be added to the device’s list of official approved indications. Of course, this determination is made by the FDA and does require additional evidence that the new indications are efficacious and safe. The 510K provision is a faster and easier way to officially bring new indications of existing lasers to the market place, however. This explains how lasers can acquire a multitude of approved indications in a relatively short period of time. Consequently, lasers can be operated by anyone and utilized for many different cutaneous processes for which there is no official indication. Due to the 510K provision, the FDA might already have approved many of the indications presented here by the time this article is published. Consequently, this is only an attempt to feature novel uses of certain lasers for the treatment of specific disease entities. Dyschromias

Erosive pustular dermatosis successfully treated with a novel silicone gel.

Erosive pustular dermatosis (EPD) is a rare inflammatory skin condition of unknown etiology. It is mostly reported as occurring on the scalp of elderly female patients following local trauma, including surgery, radiotherapy, cryotherapy, varicella zoster infections, and actinic damage. Initially, EPD is clinically characterized by erosions, large crusts, and pustules that persist and resist treatment for months or even years. It can affect large areas of the scalp and may progress to scarring alopecia. There have been reports of squamous cell carcinoma (SCC) arising within lesions of EPD. The diagnosis of EPD is usually based on clinical findings because histopathology normally shows nonspecific changes with occasional dermal lymphoplasmacytic infiltrates, atrophy, and loss of hair follicles. Direct immunofluorescence studies and bacterial and fungal cultures are negative. Case report

Commentary: Hair and Pilonidal Sinus Disease

&NA; The authors have indicated no significant interest with commercial supporters.